doi:10.1111/iej.
12867
REVIEW
A new system for classifying tooth, root and canal
anomalies
H. M. A. Ahmed1 & P. M. H. Dummer2
1
Department of Restorative Dentistry, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia; and 2School of
Dentistry, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
Abstract
Ahmed HMA, Dummer PMH. A new system for
classifying tooth, root and canal anomalies. International
Endodontic Journal, 51, 389–404, 2018.
Understanding the normal anatomical features as well
as the more unusual developmental anomalies of
teeth, roots and root canals is essential for successful
root canal treatment. In addition to various types of
root canal configuration and accessory canal mor-
phology, a wide range of developmental tooth, root
and canal anomalies exists, including C-shaped
canals, dens invaginatus, taurodontism, root fusion,
dilacerations and palato-gingival grooves. There is a
direct association between developmental anomalies
and pulp and periradicular diseases that usually
require a multidisciplinary treatment approach to
achieve a successful outcome. A number of
Introduction
Knowledge and understanding of the complexity of
root and root canal systems are basic requirements
for successful root canal treatment (Vertucci 2005).
Root and canal anatomy is complex with several sys-
tems being available for classifying root canals and
accessory canal morphology (Yoshiuchi et al. 1972,
Vertucci et al. 1974, Yoshida et al. 1975, Matsunaga
et al. 2014, Versiani & Ordinola-Zapata 2015). With
an increasing range of anatomical complexities being
Correspondence: Hany Mohamed Aly Ahmed, Department of
Restorative Dentistry, Faculty of Dentistry, University of
Malaya, 50603 Kuala Lumpur, Malaysia (Tel.:
+60129857937; e-mail: hany_endodontist@hotmail.com).
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
classifications have categorized tooth, root and canal
anomalies; however, several important details are
often missed making the classifications less than ideal
and potentially confusing. Recently, a new coding
system for classifying root, root canal and accessory
canal morphology has been introduced. The purpose
of this article is to introduce a new system for classi-
fying tooth, root and canal anomalies for use in
research, clinical practice and training, which can
serve as complementary codes to the recently
described system for classifying root, as well as main
and accessory canal morphology.
Keywords: anomalies, classification, c-shaped
canals, dens invaginatus, palato-gingival groove, tau-
rodontism.
Received 5 August 2017; accepted 9 October 2017
reported and the deficiencies of the existing systems
becoming more apparent, new systems for classifying
root, root canal (Ahmed et al. 2017a) and accessory
canal morphology (Ahmed et al. 2017b) have been
proposed to provide detailed information for use by
clinicians, trainees and academics.
The development of a tooth is a complex biological
process moderated by a series of epithelial–mesenchy-
mal interactions (Shrestha et al. 2015). Disturbance of
the epithelial–mesenchymal interactions can alter nor-
mal odontogenesis causing a developmental anomaly
[anomaly is a Greek word meaning ‘irregular’; a devia-
tion from what is regarded as normal] (Shrestha et al.
2015). Depending on the stage of tooth development,
various anomalies either in root/canal number, size
and/or shape can occur (Shrestha et al. 2015). The
International Endodontic Journal, 51, 389–404, 2018 389
 New classification for anomalies Ahmed & Dummer

Table 1 Classifications for root and root canal anomalies applied in this system

Anomaly (Author(s)/year) Classification

C-shaped canals
(Fan et al. 2007) (Figure 1)
Dens invaginatus
(Oehlers 1957) (Figure 2)
Palato-gingival groove
(Gu 2011) (Figure 3)
Radix entomolaris (Distolingual root)
(Song et al. 2010a) (Figure 4)
Root fusion
(Zhang et al. 2014) (Figure 5)
Taurodontism
(Seow & Lai 1989) (Figure 6)
Type I (Merging Type) – canal images merged into one major canal before exiting from
the apical foramen. Partial radiolucent area might appear in the coronal and/or middle
portion of the canal system
Type II (Symmetrical Type) – there were separate mesial and distal canals. The mesial
and distal canals appear to be symmetrical in their size and continued on their own
pathway to the apex. The mesial and distal borders of each canal are very clear over
the canal length
Type III (Asymmetrical Type) – there are separate mesial and distal canals. The mesial
and distal canals appear to be asymmetrical in their size and continue on their own
pathway to the apex. The distal border of distal canal and both borders of mesial canal
are clear, but the mesial border of the distal canal is blurred, which makes the distal
canal seem wider than the mesial canal
Type I – it is an enamel-lined minor form that occurs within the confines of the crown
not extending beyond the amelocemental junction
Type II – it is an enamel-lined form that invades the root but remains confined as a
blind sac. Communication with the dental pulp may or may not occur in this type
Type III – it is a form that penetrates through the root perforating at the apical area
showing a ‘second foramen’ in the apical or periodontal area (no immediate
communication occurs with the pulp). The invagination may be completely lined by
enamel, but cementum is frequently found lining the invagination
Type I – the groove is short (not beyond the coronal third of the root)
Type II – the groove is long (beyond the coronal third of the root) but shallow,
corresponding to a normal or simple root canal
Type III – the groove is long (beyond the coronal third of the root) and deep,
corresponding to a complex root canal system
Type I – no curvature
Type II – curvature in the coronal third and straight continuation to the apex
Type III – curvature in the coronal third and additional buccal curvature from the middle
third to the apical third of the root
Small type – root length less than half that of the distobuccal root
Conical type – cone-shaped (extension with no root canal)
Type 1 – MBR fused with DBR
Type 2 – MBR fused with PR
Type 3 – DBR fused with PR
Type 4 – MBR fused with DBR, PR fused MBR, or DBR
Type 5 – PR fused with MBR and DBR
Type 6 – PR MBR, and DBR fused to a cone-shaped root
[MBR – mesiobuccal root, DBR – distobuccal root, PR – palatal root]
Hypotaurodont (Hypo) – if CB : R ratio ranges from 1.10 to 1.29
Mesotaurodont (Meso) – if CB : R ranges from 1.30 to 2.00
Hypertaurodont (Hyper) – if CB : R is >2.00
(C: Crown, B: Body, R: Root)

most common root malformations in humans arise

from either developmental disorders of the root alone,
such as root dilaceration and taurodontism, or disor-
ders of root development as a part of a general tooth
dysplasia, such as dentine dysplasia type 1 (Luder
2015). There is a direct association of such develop-
mental variations with pulp and periradicular diseases
that may necessitate a multidisciplinary treatment
approach. However, even then, a wide range of clinical
outcomes may occur (Jafarzadeh & Abbott 2007, Kre-
meier & H€ ulsmann 2007, Alani & Bishop 2008, Jafar-
zadeh et al. 2008, Kato et al. 2014, Kim et al. 2017).
Justification for a new classification
system
The present systems for classifying root and canal
anomalies focus on describing details of the anomaly
and categorizing them into types based on severity or
specific morphological characteristics (Oehlers 1957,
Fan et al. 2007, Song et al. 2010a, Gu 2011, Ahmed
& Abbott 2012, Zhang et al. 2014). However, a prac-
tical classification addressing root/canal anomalies
together with the morphology of the root, main canal
system and accessory canals has not been developed.

390 International Endodontic Journal, 51, 389–404, 2018 © 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Ahmed & Dummer New classification for anomalies

Figure 1 Canal variation and 3D reconstructed canal configuration of three radiographic types of C-shaped canals (a–e) (Fan
et al. 2007). Type I (a, radiograph; b, reconstructed canal image; c, coronal third point; d, middle point; e, apical third point);
(f–j) Type II (f, radiograph; g, reconstructed canal image; h, coronal third point; i, middle point; j, apical third point); (k–o)
Type III (k, radiograph; l, reconstructed canal image; m, coronal third point; n, middle point; o, apical third point) (modified
from Fan et al. 2007, reproduced with permission from Elsevier).

In addition, existing classifications do not address (a)
the concurrent occurrence of more than one anomaly
in a tooth, such as the association of a palato-gingival
groove with a talon cusp (Fabra-Campos 1990), dens
invaginatus with dilaceration (Gound & Maixner
2004) or with dens evaginatus (Satvati et al. 2014)
or with gemination (Pallivathukal et al. 2015), or (b)
the presence of multiple examples of the same anom-
aly in one tooth, such as multiple talon cusps
(Shashikiran et al. 2005), dilaceration of more than
one root in a double- or multirooted tooth (Malcic
et al. 2006).
The new system suggested in this article provides
students/trainees, clinicians and scientists with a
standardized approach to classify tooth anomalies
using existing classifications but with additional
details on root and canal morphology that will pro-
vide more clinical relevance and impact.
New classification system for anomalies
Terminology
C-shaped canal (CsC)
A cross-sectional shape similar to the letter ‘C’, usu-
ally found in mandibular second molar teeth in which
there is a single C-shaped root or where the mesial
and distal canals communicate (or remain separate)

© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 51, 389–404, 2018 391
 New classification for anomalies Ahmed & Dummer
Figure 2 Classification for dens invaginatus (Oehlers 1957).
due to fusion of the mesial and distal roots (Kato et al.
2014, American Association of Endodontics 2016).
Concrescence (C)
A cemental fusion of roots of at least two teeth
(American Association of Endodontics 2016). It can
be of developmental or nondevelopmental origin
(Shrestha et al. 2015).
Dens evaginatus (DE)
A developmental anomaly of a tooth resulting in for-
mation of an accessory cusp whose morphology has
been variously described as an abnormal tubercle, ele-
vation, protuberance, excrescence, extrusion or bulge
(Levitan & Himel 2006). Some reports define an
accessory cusp on an anterior tooth as a ‘Talon cusp’
(Hegde et al. 2010).
Dens invaginatus (DI)
A developmental anomaly that results in an invagina-
tion of the enamel organ into the dental papilla prior to
calcification of the dental tissues (Alani & Bishop 2008).
Enamel pearl (EP)
A focal mass of enamel located apical to the cemento-
enamel junction (American Association of Endodon-
tics 2016).
Gemination (G)
A disturbance during odontogenesis in which partial
cleavage of the tooth germ occurs and results in a
392 International Endodontic Journal, 51, 389–404, 2018
tooth that has a double or ‘twin’ crown, usually not
completely separated; there is a common shared root
and pulp space (American Association of Endodontics
2016).
Palato-gingival groove (PGG)
A developmental anomaly that is usually found on
the palatal aspect of the root of a maxillary incisor
tooth, also known as radicular lingual groove or dis-
tolingual groove. It usually begins in the central fossa
area, extends over the cingulum and continues api-
cally down the root surface (Peikoff et al. 1985, Lara
et al. 2000).
Root dilaceration (RD)
A deformity characterized by displacement of the root
of a tooth from its normal alignment with the crown;
this may occur as a consequence of injury during
tooth development. Common usage has extended the
term to include sharply angular or deformed roots
(American Association of Endodontics 2016). Crown
dilaceration is another less common anomaly, com-
pared to root dilaceration, which usually occurs in
maxillary permanent incisors (Jafarzadeh & Abbott
2007).
Radix entomolaris (RE) (accessory distolingual (DL)
roots)
A supernumerary root in a mandibular molar, usu-
ally located distolingually (American Association of
Endodontics 2016).
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Ahmed & Dummer New classification for anomalies

Figure 3 Classification for palato-gingival grooves (Gu 2011). Maxillary lateral incisors with radicular grooves. (a) A mesial
groove (type I); (b) a distal groove (type I); (c) double grooves (type I, a mesial and a distal); (d) a cross-sectional V-shaped
groove (type II) extends to the apex at the mesial aspect; (e) a distal groove (type II) initiates from incisal notching (arrow) and
the mesiodistal width of the tooth is larger than usual; (f) a V-shaped groove (type II) runs distally, corresponding to a cross-
sectional teardrop-like root canal; (g) a type III radicular groove corresponds to a C-shaped canal; (h) a type III radicular
groove combined with an additional root and canal at the distal aspect (arrow); and (i) an additional root and canal at the
mesial aspect. The invagination communicates with pulp cavity via an accessory canal (arrow). (reproduced with permission
from Elsevier).

© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 51, 389–404, 2018 393
 New classification for anomalies Ahmed & Dummer

Figure 4 Classification for distolingual roots (Song et al. 2010a). Three-dimensionally reconstructed images of molars with a DL
root (arrows). The apical, lingual and distal views of the five types classified according to their morphologic characteristics (type
I: no curvature; type II: curvature in the coronal third and straight continuation to the apex; type III: curvature in the coronal
third and additional buccal curvature from the middle third to the apical third of the root; small type: root length less than half
that of the distobuccal root; conical type: cone-shaped extension with no root canal) (reproduced with permission from Elsevier).

Figure 5 Classification of root fusions (Zhang et al. 2014) (upper row: buccal view of root fusion; bottom row: apical view of
root fusion) (reproduced with permission from Elsevier).

Radix paramolaris (RP) proper horizontal level. An enlarged pulp chamber,

A supernumerary root in a mandibular molar, usu- apical displacement of the pulpal floor and no constric-
ally located mesiobuccally (American Association of tion at the level of the cemento-enamel junction are
Endodontics 2016). the characteristic features (Jafarzadeh et al. 2008).

Taurodontism (T) Tooth fusion (TF)

A change in tooth shape caused by the failure of Her- A ‘double’ tooth resulting from the union of two adja-
twig’s epithelial sheath diaphragm to invaginate at the cent tooth germs (American Association of Endodontics

394 International Endodontic Journal, 51, 389–404, 2018 © 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd

Figure 6 Classification of Taurodontism (Seow & Lai 1989).
2016). Fusion of roots in double- or multirooted teeth
is referred to as ‘root fusion’ (RF) (Zhang et al. 2014).
New coding system for root and canal
anomalies
General guidelines
The new system does not reclassify anomalies already
reported in the literature but rather aims to provide
more comprehensive information on the morphologi-
cal features of a specific tooth, root and canal within
a single code. For simplicity and to prevent confusion,
only one commonly used existing classification for
each anomaly will be taken as a reference to describe
anomalies (Table 1; Figs 1–6) with the additional
integration of the new coding system.
The new coding system can be adapted for tooth,
root and canal anomalies. It includes codes for anoma-
lies and their subtypes (if present) as described below.
Appendix S1 provides general guidelines and several
examples of codes allocated for various anomalies.
• The abbreviation of the anomaly (A) is added
between brackets. For example, (DE) refers to dens
evaginatus affecting a given tooth. If more than
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
Ahmed & Dummer New classification for anomalies
Table 2 A summary of the codes for tooth, root and canal
anomalies
Configuration Code
A tooth with a single anomaly (A)
A tooth with two or more (2A), (3A), (nA)
of the same anomaly
A tooth with two or more (A1,A2), (A1,A2,An)
of different anomalies
Tooth fusion or C-shaped canals in TN1/TN2
fused double roots with no
intercanal communication
Tooth fusion or C-shaped canals in TN1//TN2
fused double roots with
intercommunications in the root
canal and/or pulp chamber.
A, Anomaly; n, number.
one of the same anomaly exists in one tooth, then
the number is written on the left of the anomaly.
Thus, (2A) describes a tooth with two of the same
anomaly; thus, (2DE) describes a tooth with two
dens evaginatus.
• When the tooth has two or more different develop-
mental anomalies, a comma (,) should be added
between the initial letters of each anomaly (A1,
A2). Thus, (DI,RD) describes a tooth with both a
dens invaginatus and a root dilaceration.
• A slash (/) should be used in fused teeth, for
example, fusion of one tooth to a supernumerary
tooth, or fused roots in double-rooted teeth such
as C-shaped canals occurring in fused double-
rooted mandibular molars (Kato et al. 2014). Two
slashes (//) should be used in fused teeth or roots
with intercommunications in the root canal and/
or pulp chamber. (C) should be added between
teeth that demonstrate a concrescence.
• The subtype of each classified anomaly (if present)
should be written as a superscript after the abbre-
viation of the anomaly. Thus, (DII) describes a
tooth with a dens invaginatus type I (Oehlers
1957). In some instances, it may be impossible to
define a subtype of the anomaly during an exami-
nation (such as during conventional radiographic
examination), or when it is not relevant within a
specific clinical or experimental report; in such
cases, writing the abbreviation of the anomaly
without a subtype would be sufficient.
• For simplicity, the tooth number (TN) and configu-
rations of the root (in double- and multirooted
teeth), root canal and accessory canals (if present)
International Endodontic Journal, 51, 389–404, 2018 395
 New classification for anomalies Ahmed & Dummer

Figure 7 Micro-CT 3D models of single-rooted teeth with root anomalies (DE = dens evaginatus. PGG = Palato-gingival
groove) (modified from Ahmed et al. 2017a, reproduced with permission from Wiley).

should be written as described previously (Ahmed
et al. 2017a,b).
Table 2 summarizes the general guidelines for the
coding system of anomalies.
Anomalies such as dens invaginatus type III may
complicate the morphology of the root canal system
forming a ‘pseudo-canal’ (as a result of the invagina-
tion) that communicates with the periodontal liga-
ment space through a ‘pseudo-foramen’ (Goncßalves
et al. 2002, Alani & Bishop 2008). Such morphologi-
cal features are not included in the codes allocated for
roots and canals as they are not a part of the canal
system (Goncßalves et al. 2002, Alani & Bishop 2008).
On the other hand, anomalies such as radix entomo-
laris may have a cone-shaped root with no obvious
root canal space (Song et al. 2010a). Because current
three-dimensional computed tomography devices used
in clinical settings do not provide sufficient resolution
to identify narrow canals, in such situation, the canal
should be described as ‘undefined’ with the abbrevia-
tion of ‘un’.
If individuals want to use, for whatever reason,
another classification of an anomaly to highlight
other categories, or wish other morphological charac-
teristics to be described, such as classifications pro-
posed for describing the morphological features of

396 International Endodontic Journal, 51, 389–404, 2018 © 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd

Figure 8 (a) An example for tooth fusion with a supernu-
merary tooth (ST) with no canal communication ST1/111.
(b) tooth fusion with intercanal communication with the
code of ST1//111 (modified from Ahmed et al. 2017a, repro-
duced with permission from Wiley).
four-rooted maxillary molars (Christie et al. 1991,
Baratto-Filho et al. 2002), or would like to add
another anomaly not described here, such as dentino-
genesis imperfecta (Pettiette et al. 1998) and dentine
dysplasia (Ravanshad & Khayat (2006), then the clas-
sification/characteristic would need to be described in
detail with abbreviations developed for each anomaly
and its subtypes (if present) in order for the proposed
new system to be used alongside.
Figure 9 Micro-CT 3D models showing examples for anomalies affecting (a) all roots, (b) crown, (c) furcation of double/multi-
rooted teeth or (d) tooth with an accessory root (a, b, d modified from Ahmed et al. 2017a, reproduced with permission from
Wiley, c, modified from Kato et al. 2014, reproduced with permission from Wiley).
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
Ahmed & Dummer New classification for anomalies
New classification for anomalies in
single-, double- and multirooted teeth
Single-rooted teeth
The abbreviation of the anomaly (A) is added between
brackets before the tooth number (TN), that is (A)TN.
For instance, a dens evaginatus (DE) in a single-
rooted maxillary right central incisor tooth (111)
(Fig. 7a) would be described as (DE)111 (Fig. 7b).
(2DE)111 describes a single-rooted tooth 11 having 2
DE (Fig. 7c). (DE,PGG)111 describes a single-rooted
tooth 11 having a DE and a palato-gingival groove
(PGG) (Fig. 7d). (PGGI)111 describes a single-rooted
tooth 11 with a PGG type I (Fig. 7e). Figure 7f,g illus-
trates other subtypes of PGG. 1ST/111 describes a sin-
gle-rooted tooth 11 fused to a single-rooted
Supernumerary Tooth (ST) (Fig. 8a), whilst 1ST//111
describes a single-rooted tooth 11 fused to a single-
rooted ST with intercanal communication(s) (Fig. 8b).
Double- and multirooted teeth
If the anomaly is related to all roots of a double/mul-
tirooted tooth (such as root dilaceration) or crown
(such as dens evaginatus) or furcation [such as
Enamel Pearl (EP)] or the tooth has an accessory root
(s) (such as three-rooted mandibular molar), the code
should be written before the TN – as with single-
rooted teeth. Thus, (RD)237 M D describes a double-
rooted tooth 37 having a dilaceration of both roots
[mesial (M) and distal (D)] (Fig. 9a). (DE)244 B L
International Endodontic Journal, 51, 389–404, 2018 397
 New classification for anomalies Ahmed & Dummer
Figure 10 Micro-CT 3D models showing codes for C-shaped canals in mandibular second molars (modified from Kato et al.
2014, reproduced with permission from Wiley).
Figure 11 Micro-CT 3D models showing codes for anomalies
affecting one of the roots in molars. (a, modified from Ahmed
et al. 2017a, reproduced with permission from Wiley, b,
modified from Kato et al. 2014, reproduced with permission
from Wiley).
describes tooth 44 with two roots [buccal (B) and lin-
gual (L)] having a dens evaginatus (Fig. 9b).
(EP)237 M D describes tooth 37 with two roots hav-
ing an enamel pearl in the furcation (Fig. 9c).
(REI)337 M D DL describes tooth 37 with a type I
radix entomolaris (RE) (Fig. 9d). (CsCI)237 M//D
describes tooth 37 with two fused roots encasing a C-
shaped canal type I (merging type) (Fig. 10a).
(CsCII)237 M/D and (CsCIII)237 M/D describe tooth 37
with two fused roots encasing C-shaped canal types II
and III (symmetrical and unsymmetrical), respectively
(Fig. 10b,c).
If the anomaly is related to one or more roots in
double- or multirooted teeth, respectively, then the
398 International Endodontic Journal, 51, 389–404, 2018
anomaly should be written after the abbreviation of
the affected root. Thus, 247 M D(RD) describes a dou-
ble-rooted tooth in which the distal root has a dilacer-
ation (Fig. 11a). 237 M D(EP) describes tooth 37
having an enamel pearl related to the D root
(Fig. 11b).
Root fusion (RF) in three-rooted teeth is an excep-
tion from the above in which all types should be writ-
ten before the tooth number (TN). (RF1)316 MB DB P
describes a three-rooted tooth 16 having fused MB
and DB roots whilst the P is not fused (Zhang et al.
2014). (RF6)314 MB DB P describes a three-rooted
tooth 14 in which all roots are fused (Fig. 12a). Fig-
ure 12b provides an example of concrescence associ-
ated with two molar teeth. Figure 13 shows the
application of the new system with several anomalies.
Clinical implications
For practicability and simplicity, the codes for tooth,
root and canal anomalies presented in this new sys-
tem can serve as complementary codes to the recently
described system for classifying root, as well as main
and accessory canal morphology (Ahmed et al.
2017a,b; Figs 14–17; Appendix S1), and this has sev-
eral clinical implications.
• Including the anomaly in the root and canal coding
system provides more detailed information on the
morphological characteristics of a given tooth, thus
allowing proper diagnostic procedures and appro-
priate treatment planning. Including the anomaly
subtype is advantageous as they usually require dif-
ferent treatment protocols. For instance, the mor-
phological features and radiographic landmarks of
dens invaginatus type I vary from types II and III
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Ahmed & Dummer New classification for anomalies

Figure 12 Micro-CT models showing codes for root fusion (RF) and concrescence (C). (modified from Ahmed et al. 2017a,
reproduced with permission from Wiley).

(Bishop & Alani 2008). Similarly, the treatment

options for these anomalies would vary from the
application of a fissure sealant for type I to complex
root canal treatment procedures for dens invagina-
tus type III (Bishop & Alani 2008, Zhu et al. 2017).
• Defining the anomaly and listing the code before
the tooth number, root and canal morphology are
beneficial because it would explain the reason for
subsequent complex morphological variation
‘codes’ of the root and canal usually observed in
severe forms of the anomaly.
• Listing the anomaly code after the affected root(s)
if other roots are not affected is more appropriate
because unique root canal treatment procedures
are usually considered for that affected root(s) Figure 14 A micro-CT model showing an integrated formula
for the coding system for root, main canal, accessory canals
such as root dilacerations, which require consider-
and anomalies. (modified from Ahmed et al. 2017a, repro-
able skill to avoid intra-operative complications
duced with permission from Wiley).
(Jafarzadeh & Abbott (2007).

Figure 13 Drawings showing the application of the new system on several anomalies (G: gemination; RD: root dilaceration;
DI: dens invaginatus; T: taurodontism).

© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 51, 389–404, 2018 399
 New classification for anomalies Ahmed & Dummer

Figure 15 Drawings and micro-CT models showing the application of the new system on several anomalies using the new sys-
tem in an integrated manner (main canal and anomalies). (a) A single-rooted tooth 11 with dens invaginatus type I. The root
canal configuration is type 1. (b) A geminated single-rooted tooth 11 with a root canal configuration type I. (c) A double-
rooted tooth (hypertaurodont) 37. The mesial and distal root canals are type 1, and there is a common single canal coronal to
the level of root bifurcation. (d) A single-rooted tooth 11 fused to a single-rooted supernumerary tooth (ST). Both teeth have a
root canal configuration type 1 with an intercanal communication. (e) A double-rooted tooth 37 with a dilacerated distal root.
Both canals in the mesial and distal roots are type 1 (d, e, modified from Ahmed et al. 2017a, reproduced with permission from
Wiley).

• Defining tooth fusion with or without intercanal
communications is beneficial because each has its
own radiographic landmarks and treatment proto-
col. Clinicians should consider the pulp status in
instances of fusion where there is no apparent
communication between the root canal systems
(Song et al. 2010b, Cunha et al. 2015). In such
cases, the root canal treatment may be performed
on the affected tooth only, preserving the health of
the pulp in the unaffected counterpart (Cunha
et al. 2015). Communication between pulp cham-
bers of fused teeth is a common feature in such
anomalies (Turell & Zmener 1999, Ballal et al.
2007). Hence, irreversible damage to the pulp of
one tooth may involve the pulp of the other tooth,
and usually both teeth will require root canal
treatment. Indeed, cone beam computed tomogra-
phy (CBCT) aids in the decision-making for other
treatment options such as hemisection, which can
be delayed until the pulp chamber is separated,
and a precise 3D cutting plane can be planned
(Kim et al. 2011).
• The ability to add other developmental anomalies
that have rarely been reported in the endodontic

400 International Endodontic Journal, 51, 389–404, 2018 © 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Ahmed & Dummer New classification for anomalies

Figure 16 Drawings and micro-CT models showing the application of the new system on several anomalies using the new sys-
tem in an integrated manner (main and accessory canals as well as anomalies). (a) A single-rooted tooth 11 fused to a single-
rooted supernumerary tooth (ST). Both teeth have a root canal configuration type 1. The tooth 11 has an accessory canal in
the apical (A) third of the root configuration type 1 (A1). (b) A single-rooted tooth 11 fused to a single-rooted supernumerary
tooth (ST). Both teeth have a root canal configuration type 1 with an intercanal communication. The ST has an accessory
canal in the middle (M) third of the root with a configuration type 1-0 (no accessory foramen – blind). (c) A single-rooted
tooth 11 with a dens invaginatus type II. The root canal configuration is type 2-1, and an accessory canal exists in the apical
third of the root with a configuration type 2-1-0 (loop). (d) A single-rooted tooth 11 with a palato-gingival groove type III.
The tooth has a configuration type 1 canal, and an apical delta (D). (e) A double-rooted tooth 37 with fused mesial and distal
roots having a C-shaped canal type II. The root canal configuration in each root is type 1. An accessory canal type 1-2 exits
in the middle third of the distal root. (f) A single-rooted tooth 11 with a dens invaginatus type III. The root canal configuration
is type 1, and two accessory canals of configuration type 1 exist in the middle and apical thirds of the root (a, b, d, modified
from Ahmed et al. 2017a, reproduced with permission from Wiley, e, modified from Kato et al. 2014, reproduced with permis-
sion from Wiley).

literature, such as dentinogenesis imperfecta and
dentine dysplasia (de Coster 2009), allows the
opportunity for a much wider application of the
new system.
The ability to use this classification as an ‘inte-
grated system’ to describe common and unusual vari-
ations of the root and canal morphology (main,
accessory and anomalies) could be a direction for
future application in preclinical and clinical educa-
tional programmes for undergraduate and postgradu-
ate students. This could help students gain more
detailed and accurate information on this challenging
subject in a systematic manner. Indeed, it is one
promising way to translate current advances in
endodontic research and the growing body of evi-
dence obtained from contemporary technological pro-
cedures to clinical practice.
Conclusions
The new system for classifying root and canal anoma-
lies as well as other tooth anomalies related to

© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 51, 389–404, 2018 401
 New classification for anomalies Ahmed & Dummer

Figure 17 Micro-CT models showing the application of the new system on (a–c) three-rooted mandibular left second molar,
(d–f) three-rooted maxillary right first premolar (TR3 three-rooted type 3 according to Bellizzi & Hartwell 1981 classification) –
(a, d) root and main canal morphology, (b, e) root, main and accessory canal morphology, (c, f) root, main and accessory
canals as well as anomaly subtypes (integrated manner). (modified from Ahmed et al. 2017a, reproduced with permission from
Wiley).

endodontics provides an integrated, accurate and
practical system that allows students, dental practi-
tioners and researchers to classify root and canal
anomalies together with anatomical variations of root
and canals in a single code. It provides more detailed
information on the morphological features of teeth
essential for proper diagnoses and treatment as well
as training and research.
Conflict of interest
The authors have stated explicitly that there are no
conflict of interests in connection with this article.
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Supporting Information
Additional Supporting Information may be found in
the online version of this article:
Appendix S1. shows general guidelines and sev-
eral examples of codes allocated for different anoma-
lies.
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd